CurrentUnitedHealthcarePolicy CS012ID.B

Breast Reduction Surgery (for Idaho Only)

Defines UnitedHealthcare's medical policy for breast reduction surgery (reduction mammaplasty) applying only to the state of Idaho, including Idaho Medicaid Plus plans. It references InterQual criteria for medical necessity and lists applicable procedure and diagnosis codes.

Policy Summary

PayerUnitedHealthcare

PolicyBreast Reduction Surgery (for Idaho Only)

Policy CodePolicy CS012ID.B

Change TypeRevised coverage criteria and clarifications

Effective DateDec 1, 2025

Next Review Date

Key ActionProviders must demonstrate that the member meets the InterQual CP: Procedures, Reduction Mammaplasty, Female clinical criteria when requesting coverage and may be asked to provide medical records to support the request.

SourceLink

POLICY UPDATE CHANGES

Revised language pertaining to medical necessity clinical coverage criteria; removed reference to the InterQual CP: Procedures, Reduction Mammaplasty, Female, Adolescent.

Added language clarifying that benefit coverage is determined by federal, state, or contractual requirements and that medical records documentation may be required to assess whether the member meets clinical criteria but does not guarantee coverage.

Removed reference link to the Medical Policy titled Panniculectomy and Body Contouring Procedures (for Idaho Only).

1CPT code listed

1ICD-10 diagnosis code listed

Idaho

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Medical Necessity Criteria for Reduction Mammaplasty

Medical Necessity / Coverage Rationale

Breast reduction surgery is considered reconstructive and medically necessary in certain circumstances. For medical necessity clinical coverage criteria, refer to the InterQual CP: Procedures, Reduction Mammaplasty, Female.

ALL of the following

Member meets the InterQual clinical coverage criteria for reduction mammaplasty (Reduction Mammaplasty, Female).
InterQual criteria represent the clinical decision support used to determine medical necessity.

Relevant Procedure and Diagnosis Codes

Covered CPT codes (referenced)CPTCovered

19318

Breast reduction (reduction mammaplasty)

Relevant ICD-10 codes (diagnosis listed)ICD-10

N62	Hypertrophy of breast

What Providers Must Do

Documentation Required

Use InterQual criteria for medical necessity determination

Providers must demonstrate that the member meets the InterQual CP: Procedures, Reduction Mammaplasty, Female clinical criteria when requesting coverage; medical records documentation may be requested to assess whether criteria are met.

CPT 19318
ICD-10 N62

Documentation Required

Adhere to federal/state/contractual coverage requirements

Before applying this policy, providers must check the member's federal, state, or contractual benefit requirements as those may supersede the standard policy and affect coverage.

Clinical and Administrative Context

This policy treats breast reduction (reduction mammaplasty) as a reconstructive procedure that may be medically necessary when prespecified clinical criteria are met. UnitedHealthcare considers breast reduction medically necessary in certain circumstances and directs readers to the InterQual® CP: Procedures, Reduction Mammaplasty, Female for the specific clinical coverage criteria used to make determinations. (See: InterQual criteria referenced in policy.)

UnitedHealthcare may use third-party clinical decision support tools, such as InterQual, to assist in administering health benefits and determining medical necessity for procedures including reduction mammaplasty. Benefit coverage is ultimately determined by applicable federal, state, or contractual requirements, and medical records documentation may be requested to assess whether the member meets the clinical criteria but such documentation does not guarantee coverage.

Defined Terms

Definitions

InterQualA third-party clinical decision support tool UnitedHealthcare may use to assist in determining medical necessity for procedures such as reduction mammaplasty.

Recent Policy Changes

12/01/2025revisedLatest

Revised language pertaining to medical necessity clinical coverage criteria; removed reference to the InterQual CP: Procedures, Reduction Mammaplasty, Female, Adolescent. (This entry also added language clarifying that benefit coverage is determined by federal, state, or contractual requirements and that medical records documentation may be required to assess whether the member meets clinical criteria.)